Background:Viewing from a public health perspective, suicide is one of the growing concerns around the world. Most of the countries’ suicide prevention strategies focus on the multi-sectoral interventions using various stakeholders, in which health sector has a significant role and platform for the effective suicide prevention strategies. The unique features of primary health care scenario hold the availability, affordability, and accessibility which connect the community with the primary care sector on a first priority basis. The current study explores the attitude of general practitioners’ regarding suicide prevention Methods: Twelve in-depth interviews were conducted among general practitioners working in the primary health care centers both in the public and private sectors in Urban Bengaluru, Karnataka. A qualitative research design was employed and data was analysed using thematic analysis approach. Results:This study highlights the negative attitude towards the suicide, moral attitude towards helping process, religious sentiments and view towards decriminalization of suicidal act. Conclusion:In the current scenario, it is imperative toincorporate need based training and sensitization programmes for the health care providers which aids in evidence based suicide prevention strategies and practice in the primary health care sector.

Key words: General practitioner, Attitude, Suicide Prevention

Background

Public health is one of the major focused areas of every state, in which strategies are organized and planned in accordance with the promotion of health, prevention of ill health and curative measures for the eradication of existing health hazards. Irrespective of the measures taken by the various governments and international organizations the act of suicide continues to be a growing public health issue all over the world. Suicide is the act of deliberately killing oneself, which accounted for 1.4% of all deaths worldwide, making it the 15th leading cause of death in 2012 (WHO,2012) and it is multifactorial phenomenon which demands multi-level interventions for the prevention aspects and better strategies involving various stakeholders in the community. India is one of the countries with highest number of suicide in which southern India constituted the major part. In Karnataka, the number of people ending their life in a voluntary or deliberate act has varied from 12000 to 13000 per year during the years 2005-2007 (NCRB,2011). Under Bengaluru Injury Surveillance Programme (BISP) during 2007, 2417 suicides were registered with police.

In consideration of multi sectorial collaboration in suicide prevention, health system has a responsible role in the practical aspect of suicide prevention where the community directly keeping in touch with the formal primary health care sector, on the other hand, General Practitioners’ are the first professional who are readily accessible for the community in meeting health care needs, hence the identification and prevention of suicidal act become more important in this scenario. Viewing the contemporary social situation, the various researches helped to increase the knowledge about the suicidal act and epidemiology also contributed to understand the risk and protective factors associated with the suicidal behaviour (McLean, J., Maxwell et al 2008). It clearly indicates that the theoretical understandings are clear at an academic level but the implementation of prevention strategies, decentralization of ideas, and capacity buildings are relatively lacking from a practical point of view.

Primary care centers can act as a key setting for suicide prevention in which health professionals have an important role to play in preventing suicide (Saini, P., Windfuhr et al,2010). The attitude of general practitioners regarding suicide and its prevention is integral and central in the process of exploring the possibility of the same in the primary health care set up. Attitude is described as a psychological tendency often expressed by evaluating a specific entity with an element of favour or disfavour. It always consist of affective and cognitive components (Eagly, A. H., &Chaiken, S,2007)

The current study explore the attitude of general practitioners with regard to people with suicidal ideas, offering of help, attitude associated with the responses, religious sentiments and views associated with the decriminalization of suicide. It also tries to understand the training needs and gaps in the primary health care sector associated with the suicide prevention efforts and strategies.

Methodology

Setting: The study was carried out in primary health care centres-both private and public sector in Urban Bengaluru district of Karnataka, India. The health care centers were listed and later approached by the researcher, in which 3 health care centres in public sector and 6 centers in private sector involved in the research process.

Study Design: Research protocol along with the informed consent form submitted to the Institutional Ethics Committee, Behavioural Science Division, NIMHANS. A qualitative research design was adopted. Qualitative approach helps the researcher to understand the phenomenon under study in a non-numerical way and beyond the cause effect or co relational angle which helps the respondents to elaborate on their responses rather than fixing in to limited options. The researcher employed non-random judgement sampling for the selection of respondents. The researcher has approached the General Practitioners, those who were willing to participate in the study, informed verbally about the interests and aims of the research, and were also given an information sheet explaining the nature of the study and recruited after obtaining written informed consent.

Indepth interview Guide:

An in-depth interview guide with open ended questions was used to explore the attitude of general practitioners’ regarding suicide prevention. The interview guide consist of questions related general practitioners feelings or attitude towards a person who is having suicidal, their socio -cultural belief towards suicidal behaviours in general, how do they handle a patient with suicidal behaviour in their clinic and what their training needs.

Twelve in depth interviews were conducted and determined by the data saturation where in researcher identified instances of similarities and repetitions in the collected data. Twelve in-depth interviews constitute 3 respondents from the public sector and 9 respondents from the private sector. Interviews were held over a 4-month period, between November 2015 and February 2016. Interviews lasted between 70 minutes to 90 minutes, and were conducted in quiet settings within their hospital premise where there was minimal chance disturbance. The in-depth interview data were recorded and later transcribed for the analysis.

Results

Data was analysed by employing thematic analysis approach. It is a flexible qualitative method which helps in identifying and deriving themes from the data. A theme is a meaningful essence that runs through the data as a basic topic that the narrative is about. For thematic analysis, the researcher followed a systematic process; the data was coded and organized, involving the identification of themes through careful reading and re-reading of the transcribed interviews. The researcher identified verbatim which coded and grouped as themes. Themes which were similar and overlapping with other themes were again condensed and re-grouped. Attitude part four themes were emerged:

Negative attitude towards suicide

Moralistic attitude regarding help and recovery perspective

View towards De-criminalization of suicide

Religious sentiments towards suicide

Negative Attitude towards Suicide:

In exploring attitude towards suicide and people who having suicidal ideas most of the GPs initial reaction were identified as negativistic in nature. Majority of the general practitioners called suicidal people as fools, cowards, self -centred people and sinners which indicates extreme negativism towards the suicide and suicidal people. GPs also reported suicide as escapism from the realities of life and most of them felt that for attempting suicide it needs one minute courage and the same time for continuing life that courage should be there in throughout the life. The researcher has identified that only small amount of respondents ‘perceived suicide from a health care point of view and viewed from mental health perspective.

“Whenever people come with the suicidal ideas, I always get a bunch of negativism from that person, they are so pessimistic and they don’t have the word hope in their dictionary. I think they are very self-centred, and they can’t think beyond that” (Female, GP).

“Suicide very clearly I can say that it is a foolish act, the people who are expressing or threatening their family or significant others in the name of suicide, they are really burden to the family and community also, they will do all the drama because they want attention from others or they want to fulfill their needs by threatening family members.”(Male, GP).

“Most of the time people don’t have a trust in their own life and opt the suicide; I feel they are very much scared to live by thinking about the future problems and the amount of distress they are experiencing in the present. People commit suicide because they don’t want to live, they don’t want to face problems” (Male, GP).

Moralistic Attitude Regarding help and Recovery Perspective:

Many of the respondents believed in the moral responsibility of health care providers to save life of the people irrespective of caste, class, religion, social status. The majority of the respondents felt that whether the suicidal person is self-centred or demanding person, irrespective of the baseline issues, general practitioners are ready to provide basic professional help which is highly influenced on the concept of morality. Moreover, the moralistic attitude of the general practitioners limited to the professional help which is not having any kind of empathetic attitude or realization of the sufferings and pain of the people. GPs reported that showing empathy towards the suicidal person will not benefit in the clinical point of view, most of them believed that rather than empathy, empowerment is needed and the professional help reach to the level where people can think and act in a rational way. In a broader sense the attitude of the general practitioners regarding suicide, suicidal people and suicide prevention varies between a continuum of negativistic and moralistic perspective.

“If a person comes in front of me reporting suicidal ideas, inside my mind I will feel angry and irritation, but definitely I will not show those things on the face, definitely I will help the person, I will enquire about the issues and I will provide what all I can do. The person may be anyone, from any back ground; I always feel giving a moral support is important.”(Female, GP).

From a health care point of view I believe it is my duty to help a person if he/she comes in front of me, if I am avoiding them definitely I failed in following a moral duty of a doctor.”(Male GP).

View towards De-criminalization of Suicide:

Majority of the GPs felt that de-criminalization of suicide increase the rate of the suicide and most of them agreed that it is a TUGLAK reform which will not benefit in the way to prevent or reduce the suicidal risk. Many of the respondents highly criticized the de-criminalization of suicidal act, concluded that that it will increase burden on the general practitioners or those who are working in the medical field. Majority of the general practitioners believed that criminal tag of suicide acted as a prevention strategy and the removal of criminal tag can easily lead a person for opting suicide as a final solution to his/her problems.

“I think suicide should remain as a criminal activity, then there will be some fear associated with that, some scared element should be there to prevent that act. If we de- criminalize it is like giving license to people, we are paving comfortable way for committing suicide”(Female GP)

“In my opinion it will be a foolish act like suicide, at policy level you are making changes, before that you should think what will be its reflection on the society? People will misuse that. After de- criminalization, how we will introduce suicide in front of society? At least now we can say it’s a criminal act, so after this we can say that it’s personal act or what? I will not agree with this” (Male GP).

Religious Sentiments towards Suicide:

Majority of the GPs irrespective of their religious beliefs responded that suicide happen only when the individual‘s spiritual and religious side weakens, and the distance from the god act as a predictor of the suicidal behaviour. All respondents responded in a way that none of the religion advocates for the suicidal act and everyone beliefs suicide as a great sin one human being can do in the life time.

“I think most of the suicidal people have no idea about their own existence. When we look in to the suicidal act people commit suicide because of 3 important miseries, one is Adyathmika: which is the suffering of a body which may be in the form of diseases, physical disabilities etc. Second one isAdhidaiviga: which is the sufferings from the other kind and the third one is Adhibowdhiga: which is sufferings from the others. If a person cannot tolerate with the above mentioned miseries they will go for suicide, which is against natural law and it is the biggest sin, if a person commit suicide he/she become a Adrupthaathma means unsatisfied soul, this people never get moksha and they have to suffer after leaving the body.”(MaleGP)

“My religious scripts go against the suicidal act. No were mentioned suicide is allowed or encouraged to get salvation. Being a Muslim, I am always stands against suicide; it is a moral duty also. Life is precious, we are not supposed to take that, if we take we should have the capacity to give back; we don’t have that capacity so we are not eligible to take that.” (Female GP).

“I don’t believe that any religion will advocate for the suicidal act. My religion stands for the welfare of the entire humanity and not for the destruction of human self. I think those who go for suicide they don’t have firm belief in their religion and they don’t have any trust in god. If they have belief in their religion they will not go for the suicidal act.” (Male GP).

Discussion:

The current study highlights the attitude of general practitioners’ regarding suicide and its prevention aspects. Attitude is one of the factors which have great impact on the actions of a person, particularly regarding the health care sector it greatly involved with the delivery of quality service.

The attitude associated with the suicide and suicidal people seems to be negative in nature, where in GPs identified it as an act followed by the cowards, sinners and fools and majority of GPs reported getting angry while listening to people having suicidal ideas. One study from Nicaragua aimed at exploring how primary health care professionals in Nicaragua perceive young people‘s mental health problems and suicidal problems. This study also revealed that doctors and nurses were reluctant to deal with people presenting with suicidal problems at the primary health care, feelings of incompetence and attitudinal differences also reported (Medina, C. O., Kullgren, G,2014)Many studies have focused on the prevalent attitudes of health professionals towards people with suicidal behaviors, suggesting that negative attitudes, criticism and devaluation are predominant among these professionals(Samuelsson, M., &Åsberg, M,2002)

With regard to the help and recovery perspective, irrespective of negativistic personal attitude towards suicide, GPs’ reflected a moralistic attitude which is associated with the professional responsibility. Another qualitative study from Ghana, also reported moralistic attitude of nurses and approach of suicide prevention from a proscriptive perspective, the attitudes of health workers toward suicide and suicide prevention seemed to be transiting between morality and mental health (Osafo, J., Knizek, B. L,2012)

De-criminalization of suicide appeared as a destructive action as per the opinion from the GPs.Majority of the general practitioners believed that criminal tag of suicide, acted as a prevention strategy and the removal of criminal tag easily led a person to opt for suicide as a final solution for his/her problems. The GPs tend to give a religious explanation for the incidents of suicide and explained people with suicidal ideas from a spiritual point of view.

Limitations of the Study:

The study represents general practitioners working in public and private sectors, and those who given written informed consent for participation. Most of the general practitioners in public sector were unwilling to participate in the study due to apprehension associated with recording of the interview, which led to unequal representation of the public and private sector participation in the study. There are several factors like age, gender and years of working experience etc are not controlled during the participant selection, which may have impact on the aspects explored in the study.

Conclusion & Implications:

Considering from a public health point of view, suicide prevention is one of the practical strategy to reduce the rate of completed suicides, where in GPs having an increased role in assessing and preventing the suicidal act. Attitudinal differences and opinions having a considerable impact on the quality services providing in the health care sector.In the current scenario, it is imperative toincorporate need based training and sensitization programmes for the general practitioners which aids in evidence based suicide prevention strategies and practice in the primary health care sector. The mental health aspect of suicide needs to be highlighted and the mental health professionals having a professional responsibility to widen the territory of capacity building and awareness creation from the grass root level.